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Over-Reliance On Tests: Why Physicians Must Learn To Trust Themselves And Their Patients

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I met my newly admitted patient in the quiet of his private room. He was frail, elderly, and coughing up gobs of green phlegm. His nasal cannula had stepped its way across his cheek during his paroxsysms and was pointed at his right eye. Although the room was uncomfortably warm, he was shivering and asking for more blankets. I could hear his chest rattling across the room.

The young hospitalist dutifully ordered a chest X-Ray (which showed nothing of particular interest) and reported to me that the patient was fine as he was afebrile and his radiology studies were unremarkable. He would stop by and check in on him in the morning.

I shook my head in wonderment. One look at this man and you could tell he was teetering on the verge of sepsis, with a dangerous and rather nasty pneumonia on physical exam, complicated by dehydration. I started antibiotics at once, oxygen via face mask, IV fluids and drew labs to follow his white count and renal function. He perked up nicely as we averted catastrophe overnight. By the time the hospitalist arrived the next day, the patient was looking significantly better. The hospitalist left a note in the EMR about a chest cold and zipped off to see his other new consults.

Similar scenarios have played out in countless cases that I’ve encountered. Take, for example, the man whose MRI was “normal” but who had new onset hemiparesis, ataxia, and sensory loss on physical exam… The team assumed that because the MRI did not show a stroke, the patient must not have had one. He was treated for a series of dubious alternative diagnoses, became delirious on medications, and was reassessed only when a family member put her foot down about his ability to go home without being able to walk. A later MRI showed the stroke.

A woman with gastrointestinal complaints was sent to a psychiatrist for evaluation after a colonoscopy and endoscopy were normal. After further blood tests were unremarkable, she was provided counseling and an anti-depressant. A year later, a rare metastatic cancer was discovered on liver ultrasound.

Physicians have access to an ever-growing array of tests and studies, but they often forget that the results may be less sensitive or specific than their own eyes and ears. And when the two are in conflict (i.e. the patient looks terrible but the test is normal), they often default to trusting the tests.

My plea to physicians is this: Listen to your patients, trust what they are saying, then verify their complaints with your own exam, and use labs and imaging sparingly to confirm or rule out your diagnosis. Understand the limitations of each study, and do not dismiss patient complaints too easily. Keep probing and asking questions. Learn more about their concerns – open your mind to the possibility that they are on to something. Do not blame the patient because your tests aren’t picking up their problem.

And above all else – trust yourself.  If a patient doesn’t look well – obey your instincts and do not walk away because the tests are “reassuring.” Cancer, strokes, and infections will get their dirty tendrils all over your patient before that follow up study catches them red handed. And by then, it could be too late.

Newly Minted Doctors Begin Their First Jobs In July: Should You Be Afraid?

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Photo By Danny Kim

The short answer, in my opinion, is yes.

The long answer is slightly more nuanced.  As it turns out, studies suggest that one’s relative risk of death is increased in teaching hospitals by about 4-12% in July. That likely represents a small, but significant uptick in avoidable errors. It has been very difficult to quantify and document error rates related to inexperience. Intuitively we all know that professionals get better at what they do with time and practice… but how bad are doctors when they start out? Probably not equally so… and just as time is the best teacher, it is also the best weeder. Young doctors with book smarts but no clinical acumen may drop out of clinical medicine after a short course of doctoring. But before they do, they may take care of you or your loved ones.

It has been argued that young trainees “don’t practice in a vacuum” but are monitored by senior physicians, pharmacists, and nurses and therefore errors are unlikely. While I agree that this oversight is necessary and worthwhile, it is ultimately insufficient. Let me provide an illustrative example.

When I was a new intern I was assigned to a patient with curious eyelids. He was a mildly obese, middle aged man with a beard who spoke in hushed tones. What struck me the most was that he had voluminous upper eyelids. They were so strange that I couldn’t stop staring at them. He didn’t have any hives or red blotches on his skin, and his eyeballs were clear and white. There was no pus or discharge of any kind. I was so perplexed that I began to search through his medical record for answers before I embarrassed myself by asking for a consult. After many hours of digging, I discovered the smoking gun.

Apparently, he had been given repeat boluses of 1 Liter of IV normal saline by dutiful interns and residents who had not communicated with one another about who would write the order. So they all did. This man was so fluid overloaded that his eyes were literally bugging out of his head. No one had noticed the edema because of his size, and because (thank God) his heart and kidneys were young and healthy enough to handle the load without going into outright failure. Also, normal saline is such an innocuous medication that it didn’t flag any concerns by the nurses (who were also rotating through the service and busy swatting the more obvious mistakes being made by the fresh crop of interns).

If this poor patient had congestive heart failure or kidney disease, he could have been killed by well-meaning, diligent interns with salt water. Fortunately for him, he made a full recovery – and because there was technically “no harm done” I don’t even think this case was discussed in M&M (morbidity and mortality) conference, and I also doubt that anyone was reprimanded. Sounds crazy, but there are bigger fish to fry in July.

So my point is this: rookie mistakes are not always tracked, documented, addressed, or perhaps even noted. But they are real. They are scary. And they are lurking at every teaching hospital in this country. We must all remain on high alert – and question everything. Because even eyelids offer important clues, and water can kill.

***

If you or a loved one insist on falling ill in July, I recommend finding a hospital with a culture of carefulness or bring a patient advocate with you.

Why Physicians Must Not Skimp On The Physical Exam

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Like most physicians, I feel extremely rushed during the course of my work day. And every day I am tempted to cut corners to get my documentation done. The “if you didn’t document it, it didn’t happen” mantra has been beaten into us, and we have become enslaved to the quantitative. It’s tempting to rush through physical exams, assuming that if there’s anything “really bad” going on with the patient, some lab test or imaging study will eventually uncover it. Just swoop in, listen to the anterior chest wall, ask if there’s any new pain, and dash off to the next hospital bed. Then we construct a 5-page progress note in the EMR, describing the encounter, our assessment, and plan of care.

Focused physical exams have their place in follow up care, but I strongly urge us all to reconsider skimping on our exams. A fine-toothed comb should be used in any first-time meeting – because so much can be missed as we scurry about. Some examples of things I discovered during careful examination:

1. A pulsatile abdominal mass in a woman being worked up for dizziness.

2. New slurred speech in an edentulous gentleman with poorly controlled hypertension.

3. A stump abscess in a 2-year-old leg amputation.

4. A bullet lodged in the scrotum.

5. Countless stage 1 sacral decubitus and heel ulcers.

6. Melanoma.

7. Rashes that were bothering the patient for years but had not previously been addressed and cured.

8. Early cellulitis from IV site.

9. Deep venous thrombosis of the calf.

10. New onset atrial fibrillation.

11. Thrush.

12. Cataracts.

13. Peripheral neuropathies of various kinds.

14. Lateral medullary syndrome.

15. Surgical scars of all stripes – indicating previous pathology and missing organs of varying importance.

16. Normal pressure hydrocephalus in a patient who had been operated on for spinal stenosis/scoliosis.

17. Parkinson’s Disease in a patient with a fractured hip.

18. Shingles in a person with eye pain.

19. Aortic stenosis in a woman with dizziness.

20. Pleural effusions in a man complaining of anxiety.

Oftentimes I don’t find anything new and exciting that is not already a part of the patient’s medical record. But a curious thing happened to me the other day that made me reflect on the importance of the physical exam. After a careful review of a complex patient’s history, I discussed every scar and “abnormality” I discovered as I did a thorough head-to-toe review of his physical presentation. His aging body revealed more than he had remembered to say… and as our exam drew to a close, he reached out and offered me a fist-bump.

It was charming and unexpected – but made me realize the true importance of the thorough exam. I had gotten to know him in the process, I had earned his trust, and we had built the kind of therapeutic relationship upon which good healthcare is based. No EMR documentation effort was worth missing out on this interaction.

You may not uncover a new diagnosis on each physical exam, but you can gain something just as important. The confidence and respect of the patient.

Why Do Patients Lie To Doctors?

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Popular TV doctor, Gregory House’s favorite adage about patients is: “everybody lies.” I used to believe that this was a cynical and inaccurate statement, but I had to revisit it recently when faced with a patient whose signs and symptoms were consistent with a diagnosis that she vehemently denied.

A young woman was admitted to my rehab unit with brain damage of unclear cause. She adamantly denied drug or alcohol use, and I couldn’t help but wonder if she was suffering from a genetic or autoimmune disorder that the academic neurology team had somehow overlooked. I had recently read the New York Times best-seller, Brain on Fire and feared that I would be like one of those dismissive physicians who missed the author’s unusual diagnosis and nearly killed her from their inaction.

But staring me in the face were the specific physical manifestations of drug and alcohol abuse, though her urine toxicology screen proved she hadn’t used in the very recent past. I asked her again and again if she recalled any exposure to them – probing for an admission of even a small amount of recreational use. She remained adamant. An exhaustive work up had in fact revealed some vitamin deficiencies, the only hard evidence of anything that could explain her very real and devastating impairments. This was not a case of faking symptoms – at least I was sure of that much. Yet her situation continued to haunt me, because until she came clean about the cause of her condition, lingering doubt would drive me to continue the “million dollar work up.”

And for this young and desperately lonely person, the “million dollar work up” may have been her only chance at experiencing ongoing concern for her well being from others. If she admitted to drug use, then the only people who seemed to care about her (sadly, even if it was mostly because she could make a “great case for Grand Rounds”) would probably turn their backs. With the mystery solved, this fascinating neurological conundrum would become a garden variety drug abuser. A person who was, perhaps, not so much a victim as a perpetrator of their own condition.

I don’t believe that those whose conditions are contributed to by their behaviors receive poorer medical care (consider the smoker with lung cancer, or the person with multiple fractures from a bridge-jump suicide attempt – their quality of care will be similar to non-smokers with lung cancer or people with orthopedic needs from a motor vehicle accident). But there may be a subtle and unspoken judgmental attitude held by some of their caregivers and providers.

Fellow friend and blogger, Kerri Morrone Sparling suggests that fear of judgment, and the guilt and shame associated with self-induced harm, are the main reasons why people with diabetes may not come clean to their endocrinologists about their eating and exercise habits. She writes,

Finding enough confidence in myself to admit my shortcomings to my doctor, who I aim to impress with my efforts, was a tall order. For me, it took finding an endocrinologist I trusted with the truth, including the parts of the truth that weren’t so pretty. I know the best doctor for me is one who cares about my emotional response to diabetes, as well as my physical response. It took some trial-and-error, but eventually I found an endo who I felt didn’t judge, but listened and helped me find reasonable solutions to my problems with “reasonable” defined as something I would actually follow through on. Instead of a blanket response of “Do everything. Try harder,” my endo helps me build off of small successes in pursuit of better outcomes.

So patients lie to their doctors because they don’t want to be abandoned, judged, or shamed. And until they are quite certain that this will not happen to them, they are likely to continue withholding information from those who are ostensibly trying to help.  The problem of lying does not rest squarely on the shoulders of patients – it is also the responsibility of physicians to make it safe for them to tell the truth. They will commit to honesty when we commit to compassion.

As I look back at my interactions with the young woman with the “mystery” illness, it is not so much the fear of missing the right diagnosis that haunts me now. It is that I did not make her feel safe enough to tell me the truth. In the end, the “million dollar work up” offered her little value for the cost and used up precious healthcare resources.

What she needed was a safe place to live, a supportive environment, a program for drug counseling, and job training for those with disabilities. I missed out on really helping this patient because I was more comfortable with searching for a rare diagnosis than pursuing treatment for the all-too-common, nebulous cycle of social ills that poverty, drugs and abuse cause. Maybe I wanted to believe her lie because at least then there was a chance I could fix her?

As it turns out, I was as invested in her lie as she was – we just had different reasons for it. While she did not want to be abandoned or shamed, I did not want to have to face the fact that I had very little to offer her.

Dr. House was right – under certain circumstances, patients are likely to lie. The other side of the coin, though rarely discussed, is that sometimes doctors are complicit in keeping those lies going.

Why Patient Autonomy Is Critical To Good Health Care

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Many of the patients that I treat have brain injuries. Whether caused by a stroke, car accident, fall, or drug overdose, their rehab course has taught me one thing: nobody likes to be forced to do things against their will. Even the most devastated brains seem to remain dimly aware of their loss of independence and buck against it. Sadly, the hospital environment is designed for staff convenience, not patient autonomy.

In the course of one of my recent days, I witnessed a few patient-staff exchanges that sent me a clear message. First was a young man with a severe brain injury who was admitted from an outside hospital. EMS had placed him in a straight jacket to control his behavior on his trip and by the time I met him, he was in a total panic. Sweating, thrashing, at risk for self harm. He didn’t have the ability to understand fully what was happening but one thing he knew – he was being restrained against his will. The staff rushed to give him a large dose of intramuscular Ativan, but I had a feeling that he would calm down naturally if we got him into a quiet room with dim lights and a mattress with wall padding set up on the floor. As it turned out, the environmental intervention was much more successful than the medicine. Within minutes of being freed to move as he liked, he stopped moving much at all.

Later I was speaking with one of my patients in the shared dining room. An aide arrived with a terry cloth bib to tie around his neck so that he didn’t spill anything during lunch. I saw a flash of anger in my patient’s eyes as he pulled the bib away from his neck with his good arm and placed the towel on his lap instead. I could tell that he found the bib infantalizing, though none of us had thought twice about it before. Here again, a patient did not appreciate having everything determined for him, right down to napkin placement.

Towards the end of the day, I was bidding farewell to a patient whose care would be provided by another attending physician going forward. I was summarizing my view of his progress and expectations for the future, and stopped to ask if he had any questions. What he asked completely flummoxed me. Instead of probing for details about his medical condition and treatment options, he asked, “Will the new doctor be a good listener? Will she pay attention to what I’m saying and be easy to talk to?”

It is unfortunate that healthcare providers and patients are often on very different wavelengths. In Atul Gawande’s recent book, Being Mortal, he argues that nursing homes have often failed to provide healthy environments for patients because they have focused exclusively on safety and meeting basic needs (eating, dressing, bathing, etc.) on their terms. The removal of patient independence unwittingly results in devastating loneliness, helplessness, and depression. It seems to me that hospitals end up doing the same thing to patients – if only for a shorter period of time.

I was moved by Gawande’s book (and I consider it required reading for anyone facing a life-limiting illness or caring for someone who is). It renewed my conviction about the importance of rehabilitation – helping people to become as functionally independent as possible after a devastating injury or disease. Even as we age, we all become less able to do the things we hold dear. Preserving dignity by prolonging independence, and respecting patient autonomy, are often overlooked goals of good health care. It’s time to think about what our actions – even as small as placing a bib around someone’s neck – are doing to our patients’ morale. Maybe it starts with asking the right questions… Or better yet, just watching and listening.

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